EXTENSION ATTACHED Form 990 -PF Return of Private Foundation or Section 4947 (a)(1) Nonexempt Charitable Trust Department of the Treasury Treated as a Private Foundation Internal Revenue Service Note The foundation may be able to use a copy of this return to satisfy state reporto For calendar year 2012 or tax year beginning 10/01 , 2012 , and endil Name of foundation BLAKE ELIN VANDERLIP MEMORIAL FOUNDATION N 0- W Cf) z OMB No 1545-0052 2012 09/30, 2013 A Employer identification number 13-3492208 Number and street (or P 0 box number if mail is not delivered to street address) Room/ suite B Telephone number (see instructions) C/O HENRIK VANDERLIP (203) 861-7300 27 BALDWIN FARMS SOUTH City or town, state, and ZIP code C If exemption application is ► q pending , check here • • • • • GREENWICH, CT 06831 G Check all that apply- Initial return Initial return of a former public charity D 1 Foreign organizations , check here • Final return Amended return 2 Foreign organizations meeting the Address change Name chan ge 85% test, check here and attach ► El computation H Check type of organization X Section 501(c 3 exempt private foundation E if private foundation status was terminated El Section 4947 ( a )( 1 nonexem p t charitable trust Other taxable p rivate foundation under section 507(b)(1)(A), check here . ► I Fair market value of all assets at end J Accounting method X Cash Accrual F If the foundation is in a 60-month termination of year (from Part ll, col (c), line El Other (specify) - -- - - -- - ---- - under section 507(b)(1 )(B), check here , ► 16) ► $ 2,153. (Part 1, column (d) must be on cash basis) Analysis of Revenue and Expenses (The total of amounts in columns (b), (c), and (d) (a) Revenue and (b) Net investment (c) Adjusted net (d) Disbursements for charitable may not necessarily equal the amounts in expenses per books income income purposes column (a)(see instructions ( cash basis onl y) 1 Contribution s a. efts, grants , etc , received ( attach schedule ) 35,890. , 2 Check ► I I if the foundation is not required to LJ attach Sch B 3 Interest on savings and temporary cash investments 4 4 . ATCH 1 4 Dividends and interest from securities 5a Gross rents . . . . . . . . . . . . . . . . . b Net rental income or (loss) a) 6a Net gain or (loss) from sale of assets not on line 10 -1,756. b Gross sales puce for all 34 , 134 . assets on line 6a w w 7 Capital gain net income (from Part IV, line 2) 29,005. 8 Net short-term capital gain . . . . . . . . . 9 Income modifications • • • • • • • • • • 10 a Gross sales less returns and allowances b Less Cost of goods sold c Gross profit or (loss) (attach schedule) . 11 Other income (attach schedule) . . • . . . . 12 Total Add lines 1 throu gh 11 34, 138. 29, 009. 13 Compensation of officers, directors, trustees, etc . in 14 Other employee salaries and wages . . . , m u) 15 Pension plans, employee benefits a . . . . . 16a Legarfees atIarJt sche to, . b Accountl (atth she , , • c Other professional fees (attach schedirfe). `c° 17 Inte e tI. . JE? C 9.2•0 4 . I ^I I C 18 Tax s (attach schedule) (see instructions) E i 19 Depreciation attach-schedule)artddK jlletion, l I Q t panc PGJ N.,.UT. 20 Oc .. . 21 Travel, conferences, and meetings 1° 22 Printing and publications . . . . . . . . . . 23 Other expenses (attach schedule) . . . . . 24 Total operating and administrative expenses. Add lines 13 through 23 . . . . . . . . . 0 25 Contributions, gifts, grants paid . • • • • 32,898. 32, 898 26 Total ex p enses and disbursements Add lines 24 and 25 32,898. 32,898 27 Subtract line 26 from line 12 a Excess of revenue over expenses and disbursements 1,240. b Net investment income (if negative, enter -0-) 29,009. c Adjusted net income ( if ne g ative , enter -0- ) . . SSA For Paperwork Reduction Act Notice, see instructions . Form 9aU-II (2012) 2E1410 1000 4KL01T L161 8/8/2014 2: 53:22 PM V 12-7.12 26895
Transcript
EXTENSION ATTACHED
Form 990-PF Return of Private Foundationor Section 4947 (a)(1) Nonexempt Charitable Trust
Department of the Treasury Treated as a Private FoundationInternal Revenue Service Note The foundation may be able to use a copy of this return to satisfy state reporto
For calendar year 2012 or tax year beginning 10/01 , 2012 , and endil
Name of foundation
BLAKE ELIN VANDERLIP MEMORIAL FOUNDATION
N
0-WCf)
z
OMB No 1545-0052
201209/30, 2013
A Employer identification number
13-3492208
Number and street (or P 0 box number if mail is not delivered to street address) Room/ suite B Telephone number (see instructions)
C/O HENRIK VANDERLIP (203) 861-7300
27 BALDWIN FARMS SOUTHCity or town, state, and ZIP code
C If exemption application is ► qpending , check here • • • • •
GREENWICH, CT 06831
G Check all that apply- Initial return Initial return of a former public charity D 1 Foreign organizations , check here •
Final return Amended return 2 Foreign organizations meeting the
Address change Name chang e85% test, check here and attach ►
Elcomputation
H Check type of organization X Section 501(c 3 exempt private foundationE if private foundation status was terminated
ElSection 4947 ( a )( 1 nonexem pt charitable trust Other taxable p rivate foundation under section 507(b)(1)(A), check here . ►
I Fair market value of all assets at end J Accounting method X Cash Accrual F If the foundation is in a 60-month termination
of year (from Part ll, col (c), line El Other (specify) -
- - - - - - -
- - - - -
under section 507(b)(1 )(B), check here , ►
16) ► $ 2,153. (Part 1, column (d) must be on cash basis)
Analysis of Revenue and Expenses (Thetotal of amounts in columns (b), (c), and (d)
(a) Revenue and (b) Net investment (c) Adjusted net(d) Disbursements
for charitable
may not necessarily equal the amounts inexpenses per
C'MM Anal sis of Changes in Net Assets or Fund Balances1 Total net assets or fund balances at beginning of year - Part II, column (a), line 30 (must agree with
eComplete onl y for assets showin g g ain in column ( h ) and owned by the foundation on 12/31/69 (I) Gains (Col (h) gain minus
(i) F M V as of 12/31 /69 (!) Adjusted basisas of 12 / 31/69
( k) Excess of col (i)over col 0), if any
col ( k), but not less than -0-) orLosses (from col (h))
a -
b
cd
e
2 Capital gain net income or ( net capital loss){
If gain, also enter in Part I, line 7
If (loss), enter -0- in Part I, line 7 } 2 29,005.
3 Net short-term capital gain or (loss) as defined in sections 1222 ( 5) and (6)
If gain , also enter in Part I, line 8, column (c) (see instructions ) If (loss ), enter -0- in
Part I, line 8 3 0
1:F-Ti-i&T' Qualification Under Section 4940(e) for Reduced Tax on Net Investment Income(For optional use by domestic private foundations subject to the section 4940(a) tax on net investment income )
If section 4940(d)(2) applies, leave this part blank
Was the foundation liable for the section 4942 tax on the distributable amount of any year in the base period? q Yes NoIf "Yes," the fou ndation does not qualify under section 4940(e) Do not complete this part.
-t triter one appropriate amount in eacn column ror earn year , see me instructions Derore making any entries
Base period yearsCalendar year ( or tax year beginning in) Adjusted bdistributionsqualifying Net value of nonc(hantable-use assets
Distribution ratio(col ( b) divided by col (c))
2011 13,545. 9,907. 1.367215
2010 37,508. 35,146. 1.067205
2009 49,290. 69,058. 0.713748
2008 55,865. 88,880. 0.628544
2007 116,705. 24,106. 4.841326
2 Total of line 1, column (d) 2 8.618038
3 Average distribution ratio for the 5-year base period - divide the total on line 2 by 5, or by the
number of years the foundation has been in existence if less than 5 years , , , , , , , , , , , 3 1.723608
4 Enter the net value of noncharltable - use assets for 2012 from Part X , line 5 4 12,895.
5 Multiply line 4 by line 3 . . . . . . . . . . . . . . . . . . . 5 22,226.
6 Enter 1% of net investment income ( 1%of Part I , line 27b ) . . . . . . . . . . . . . . . 6 290.
7 Add lines 5 and 6
. . . . .
7 22,516.
8 Enter qualifying distributions from Part XII , line 4
*
8 32,898.If line 8 is equal to or Greater than line 7 . check the box in Part VI . line 16.b. and comDlete t hat D art uslna a 1% tax rate See thePart VI Instructions
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orm 990-PF (2012) BLAKE ELIN VANDERLIP MEMORIAL FOUNDATION 13-3492208 Page 4
MET Excise Tax Based on Investment Income (Section 4940 (a), 4940 ( b), 4940 ( e), or 4948 - see instructions)
1 a Exempt operating foundations described in section 4940(d)(2), check here ► and enter "N/A" on line 1 , , ,
Date of ruling or determination letter --------------- (attach copy of letter if necessary - see instructions)
b Domestic foundations that meet the section 4940(e) requirements in Part V, check 1 290.
here ► and enter 1 % of Part I, line 27b
c All other domestic foundations enter 2% of line 27b Exempt foreign organizations enter 4% of
Part I, line 12, col (b)
2 Tax under section 511 (domestic section 4947(a)(1) trusts and taxable foundations only Others enter -0-) . .
3 Add lines 1 and 2 3 290.
4 Subtitle A (income) tax (domestic section 4947(a)(1) trusts and taxable foundations only Others enter -0-) , 4 0
5 Tax based on investment income Subtract line 4 from line 3 If zero or less, enter -0- , , , , , , , , , 5 290.
6 Credits/Payments
a 2012 estimated tax payments and 2011 overpayment credited to 2012 6a 1,935.
b Exempt foreign organizations - tax withheld at source , , , , , , , 6b
c Tax paid with application for extension of time to file (Form 8868), , , . , , , 6c
8 Enter any penalty for underpayment of estimated tax Check here q if Form 2220 is attached , , , . , , ,
9 Tax due If the total of lines 5 and 8 is more than line 7, enter amount owed . . . . . . . . ►
10 Overpayment If line 7 is more than the total of lines 5 and 8, enter the amount overpaid , , ,- . ►11 Enter the amount of line 10 to be Credited to 2013 estimated tax ► 1, 645. Refunded ►
Statements Regarding Activities
la During the tax year , did the foundation attempt to influence any national, state, or local legislation or did it participate
If the answer is "Yes" to la or 1b, attach a detailed description of the activities and copies of any materials published or
distributed by the foundation In connection with the activities
c Did the foundation file Form 1120 -POL for this year? , , , , , , , , , , ,
d Enter the amount ( if any ) of tax on political expenditures ( section 4955 ) imposed during the year
(1) On the foundation ► $ (2) On foundation managers ► $
e Enter the reimbursement (if any ) paid by the foundation during the year for political expenditure tax imposed on
foundation managers ► $
2 Has the foundation engaged in any activities that have not previously been reported to the IRS?, , , , , , , , , , , , , ,
If "Yes, " attach a detailed description of the activities
3 Has the foundation made any changes, not previously reported to the IRS, in its governing instrument, articles of incorporation,
or bylaws, or other similar instruments ' If "Yes," attach a conformed copy of the changes . . . . . . . . . . . . . . . . . . .
4a Did the foundation have unrelated business gross income of $1,000 or more during the year? . . . . . . . . . . . . . . . . .
b If "Yes," has it filed a tax return on Form 990 -T for this year? , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,
5 Was there a liquidation, termination, dissolution, or substantial contraction during the year?, , , , , , , , , , , , , , , , , ,
If "Yes," attach the statement required by General Instruction T
6 Are the requirements of section 508(e) (relating to sections 4941 through 4945) satisfied either
• By language in the governing instrument, or
• By state legislation that effectively amends the governing instrument so that no mandatory directions that conflict
with the state law remain in the governing instrument? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7 Did the foundation have at least $5,000 in assets at any time during the year? If "Yes," complete Part II, col (c), and Part XV
8a Enter the states to which the foundation reports or with which it is registered ( see instructions) ►NY,
----------------------------------------------------------------------------b If the answer is "Yes" to line 7 , has the foundation furnished a copy of Form 990-PF to the Attorney General ( or designate)
of each state as required by General Instruction G2lf "No," attach explanation . . . . . . . . . . . . . . . . . . . . . . . . .
9 Is the foundation claiming status as a private operating foundation within the meaning of section 4942(j)(3) or
4942 (j)(5) for calendar year 2012 or the taxable year beginning in 2012 (see instructions for Part XIV)' If "Yes," complete
Part XIV ..........................................................
10 Did any persons become substantial contributors during the tax year? If "Yes," attach a schedule listing their names and
addresses
1, 935.
1,645.
Yes No
la X
lb X
Ic X
2 X-
3 X
4a X
4b
5 X
6 X
7 X
8b X
9 X
10 X
Form 990-PF (2012)
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Statements Regarding Activities (continued)
11 At any time during the year , did the foundation , directly or indirectly , own a controlled entity within the
meaning of section 512 (b)(13)? If "Yes," attach schedule ( see instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 X
12 Did the foundation make a distribution to a donor advised fund over which the foundation or a disqualified
person had advisory privileges? If 'Yes," attach statement ( see instructions ) . . . . . . . . . . . . . . . . . . . . . . . . 12 X
13 Did the foundation comply with the public inspection requirements for its annual returns and exemption application ? . . . . 13
b Did the foundation, during the year, pay premiums, directly or indirectly, on a personal benefit contract? . . . . . . . . . . . . 6b X
If "Yes" to 6b, file Form 8870 -
7a At any time during the tax year, was the foundation a party to a prohibited tax shelter transaction? q Yes q No
b If "Yes," did the foundation receive an y proceeds or have an y net income attributable to the transaction? 7b X
Information About Officers , Directors, Trustees , Foundation Managers , Highly Paid Employees,
I List all officers . directors . trustees . foundation managers and their compensation (see instructions).
(a) Name and address(b) Title, and average
hours per weekdevoted to position
(c) Compensation( If not paid ,enter -0-
(d) Contributions toemployee benefit plans
and deferred compensation
(e) Expense account,other allowances
-------------------------------------ATCH 2 0
-------------------------------------
-------------------------------------
-------------------------------------
2 Compensation of five highest-paid employees (other than those included on line 1 - see instructions). If none, enter"NONE."
(a) Name and address of each employee paid more than $50,000(b) Title, and average
hours per weekdevoted to position
(c) Compensation
(d) Contributions toemployee benefitplans and deferred
compensation
(e) Expense account,other allowances
-------------------------------------NONE
-------------------------------------
-------------------------------------
-------------------------------------
-------------------------------------
Total number of other em p lo yees paid over $ 50,000 . ►Form 990-PF (2012)
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Information About Officers, Directors , Trustees , Foundation Managers , Highly Paid Employees,and Contractors (continued)
3 Five highest - paid inde pendent contractors for professional services ( see instructions ) . If none , enter "NONE."(a) Name and address of each person paid more than $50 , 000 (b) Type of service (c) Compensation
NONE
Summary of Direct Charitable Activities
List the foundat ion 's four largest direct charitable activities during the tax year Include relevant statistical information such as the number oforganizations and other beneficiaries served, conferences convened , research papers produced, etc
e Reduction claimed for blockage or other factors reported on lines 1 a and
1c (attach detailed explanation) . .. . le
2 Acquisition indebtedness applicable to line 1 assets 2. . .. . . .. . . . ...
3 Subtract line 2 from line 1d
.
.
3 13,091..........................................4 Cash deemed held for charitable activities Enter 1 1/2 % of line 3 (for greater amount, see
, ,instructions) . ...... 4 196.. . . .. ... ........ ... ......... , . . .5 Net value of noncharitable - use assets . Subtract line 4 from line 3 Enter here and on Part V, line 4 5 12,895.
6 Minimum investment return Enter 5% of line 5 6 645.
Distributable Amount (see instructions) (Section 4942(j)(3) and (j)(5) private operating)foundations and certain foreign organizations check here ► and do not complete this part
a Expenses, contributions, gifts, etc. - total from Part I, column (d), line 26 . . ... . . . . . . . . . 1a 32,898.
b Program-related investments - total from Part IX-B 1 b.. ... .. ....... .2 Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc ,
purposes . . . 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... ....3 Amounts set aside for specific charitable projects that satisfy the
, , , , , , , , , , , , , , , , , ,b Cash distribution test (attach the required schedule) 3b, , , , ,
4 Qualifying distributions . Add lines 1 a through 3b Enter here and on Part V, line 8, and Part XIII, line 4 , , , , , , 4 32,898.
5 Foundations that qualify under section 4940(e) for the reduced rate of tax on net investment income.
Enter 1 % of Part I, line 27b (see instructions), , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 5 290.
6 Adjusted qualifying distributions . Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . 6 32, 608.
Note . The amount on line 6 will be used in Part V, column (b), in subsequent years when calqualifies for the section 4940(e) reduction of tax in those years.
culati ng whether the foundation
Form 990-PF (2012)
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Undistributed Income ( see instructions)
(a) (b) (c) (d)
1 Distributable amount for 2012 from Part XI , Corpus Years prior to 2011 2011 2012
line 7 ..................... 355.
2 Undistributed income, if any , as of the end of 2012
a Enter amount for 2011 only . . . . . . . . . .
b Total for pnor years 20 10 ,20 0 9 20 08
3 Excess distributions carryover, if any, to 2012
a From 2007 116, 380.
b From 2008 53,280.
c From 2009 45,837.
d From 2010 35,752.
e From 2011 13,050.
f Total of lines 3a through e , , , , , , , , , , , 264,299.
4 Qualifying distributions for 2012 from Part XII,
line4 ► $ 32, 898.
a Applied to 2011 , but not more than line 2a , , ,
b Applied to undistributed income of prior years(Election required - see instructions ). . . . . . .
c Treated as distributions out of corpus ( Electionrequired - see instructions ) . . . . . . . . . . .
d Applied to 2012 distributable amount , , , , , 355.
e Remaining amount distributed out of corpus . . 32,543.
5 Excess distributions carryover applied to 2012 ,(If an amount appears in column (d), the sameamount must be shown in column (a) )
6 Enter the net total of each column asindicated below:
a Corpus Add lines 3f , 4c, and 4e Subtract line 5 296,842.
b Prior years' undistributed income Subtractline 4b from line 2b
c Enter the amount of prior years ' undistributedincome for which a notice of deficiency has beenissued , or on which the section 4942(a) tax hasbeen previously assessed . . . . . . . . . . . .
.
d Subtract line 6c from line 6b Taxableamount - see instructions
e Undistributed income for 2011 Subtract line4a from line 2a Taxable amount - seeinstructions . . . . . . . . . . . . . . . . . .
f Undistributed income for 2012 Subtract lines4d and 5 from line 1 This amount must bedistributed in 2013 . . . . . . . . . . . . . .
7 Amounts treated as distributions out of corpus
to satisfy requirements imposed by section
1 70(b)( 1)(F) or 4942 ( g)(3) (see instructions)
8 Excess distributions carryover from 2007 not
applied on line 5 or line 7 ( see instructions ) . . 116,380.
9 Excess distributions carryover to 2013.
Subtract lines 7 and 8 from line 6a 180,462.
10 Analysis of line 9
a Excess from 2008 . 53,280.
b Excess from 2009 . 45,837.
c Excess from 2010 . 35,752.
d Excess from 2011 , 13,050.
e Excess from 2012 . 32,543.
Form 990-PF (2012)
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FURVA9 Private Operating Foundations ( see instructions and Part VII -A, q uestion 9 ) NOT APPLICABLE
1 a If the foundation has received a ruling or determination letter that it is a private operating
foundation , and the ruling is effective for 2012, enter the date of the ruling ►b Check box to indicate whether the foundation is a private operating foundation described in section 4942 (j)(3) or 4942(j)(5)
2a Enter the lesser of the ad-justed net income from Partor the minimum investment
return from Part X for eachyear listed . . . . . . ,
Supplementary Information (Complete this part only if the foundation had $5,000 or more in assetsat any time during the year - see instructions.)
1 Information Regarding Foundation Managers:
a List any managers of the foundation who have contributed more than 2% of the total contributions received by the foundationbefore the close of any tax year (but only if they have contributed more than $5,000). (See section 507(d)(2) )
HENRIK VANDERLIP
b List any managers of the foundation who own 10% or more of the stock of a corporation (or an equally large portion of the
ownership of a partnership or other entity) of which the foundation has a 10% or greater interest
NONE
2 Information Regarding Contribution , Grant , Gift, Loan , Scholarship, etc., Programs:
Check here lo- 0 if the foundation only makes contributions to preselected charitable organizations and does not acceptunsolicited requests for funds. If the foundation makes gifts, grants, etc (see instructions) to individuals or organizations underother conditions, complete items 2a, b, c, and d.
a The name, address, and telephone number or e-mail of the person to whom applications should be addressed
b The form in which applications should be submitted and information and materials they should include.
N/A
c Any submission deadlines
N/A
d Any restrictions or limitations on awards , such as by geographical areas, charitable fields, kinds of institutions, orfactors
JA
N/A
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BLAKE ELIN VANDERLIP MEMORIAL FOUNDATION 13-3492208
Form 990-PF (2012) Page 11
Supplementary Information (continued)
3 Grants and Contributions Paid During the Year or Approved for Future PaymentReci p ient If recipient is an individual,
show any relationship toFoundation Purpose of grant or A t
Name and address (home or business ) foundationorany
(6) Performance of services or membership or fundraising solicitations . . .. . . . . . . . . .. ... . .. . . . 1b s X
c Sharing of facilities, equipment, mailing lists, other assets, or paid employees . . . . . . . . . .. . . . . . . . . . 1c
d If the answer to any of the above is "Yes," complete the following schedule Column (b) should always show the fair market
value of the goods, other assets, or services given by the reporting foundation If the foundation received less than fair market
value in any transaction or sharing arrangement, show in column (d) the value of the goods, other assets, or services received
(a) Line no (b) Amount involved (c) Name of nonchantable exempt organization (d) Description of transfers, transactions , and sharing arrangements
N/A N/A
2a Is the foundation directly or indirectly affiliated with, or related to, one or more tax-exempt organizations
described in section 501(c) of the Code (other than section 501 (c)(3)) or in section 5277 .. ... . .. .. . . . q Yes No
In If "Yac " cmmr)lete the fnllowlnn schPriule
(a) Name of organization (b) Type of organization (c) Description of relationship
Under penalties of perjury, I declare that I have examined this return , including accompanying schedules and statements , and to the best of my knowledge and belief, it is true,correct, and complete Declaration of preparer ( other than taxpayer) is based on all information of which preparer has any knowledge
Sign
Here /Signature of officer or trustee Date
Print/Type preparer's name Prepar sl aturPaid
HRISTOPHER LOIACONO
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Schedule B(Form 990 , 990-EZ,or 990-PF)Department of the Treasury
Schedule of Contributors
► Attach to Form 990, Form 990-EZ, or Form 990-PF.
OMB No 1545-0047
2012Name of the organization
BLAKE ELIN VANDERLIP MEMORIAL FOUNDATION
Organization type (check one)
Filers of:
Form 990 or 990-EZ
Form 990-PF
Employer identification number
13-3492208
Section:
q 501(c)( ) (enter number) organization
q 4947(a)(1) nonexempt charitable trust not treated as a private foundation
q 527 political organization
501(c)(3) exempt private foundation
q 4947(a)(1) nonexempt charitable trust treated as a private foundation
q 501(c)(3) taxable private foundation
Check if your organization is covered by the General Rule or a Special Rule.
Note . Only a section 501 (c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule See
instructions
General Rule
For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, $5,000 or more (in money or
property) from any one contributor Complete Parts I and II
Special Rules
q For a section 501(c)(3) organization filing Form 990 or 990-EZ that met the 33 1/3 % support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vl) and received from any one contributor, during the year, a contribution of
the greater of (1) $5,000 or (2) 2% of the amount on (I) Form 990, Part VIII, line 1 h, or (ii) Form 990-EZ, line 1
Complete Parts I and II
q For a section 501(c)(7), (8), or (10) organization filing Form 990 or 990-EZ that received from anyone contributor,
during the year, total contributions of more than $1,000 for use exclusively for religious, charitable, scientific, literary,
or educational purposes, or the prevention of cruelty to children or animals Complete Parts I, II, and III
q For a section 501(c)(7), (8), or (10) organization filing Form 990 or 990-EZ that received from anyone contributor,
during the year, contributions for use exclusively for religious, charitable, etc , purposes, but these contributions did
not total to more than $1,000 If this box is checked, enter here the total contributions that were received during the
year for an exclusively religious, charitable, etc , purpose. Do not complete any of the parts unless the General Rule
applies to this organization because it received nonexclusively religious, charitable, etc , contributions of $5,000 or
more during the year . . . .. .. . . . ... ... . .. . .. . ... . . .. ... ... ... . . ► $---------------
Caution . An organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer "No" on Part IV, line 2 of its Form 990; or check the box on line H of Its Form 990-EZ or on
Part I, line 2 of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990, 990-EZ, or 990-PF).
For Paperwork Reduction Act Notice, see the Instructions for Form 990, 990-EZ, or 990-PF Schedule B (Form 990, 990-EZ, or 990-PF) (2012)
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Schedule B (Form 990, 990-EZ, or 990-PF) (2012) Page 2
Name of organization BLAKE ELIN VANDERLIP MEMORIAL FOUNDATION
1
Employer identification number
13-3492208
Contributors (see instructions) Use duplicate copies of Part I if additional space is needed
(a) (b) (c) (d)No. Name , address , and ZIP + 4 Total contributions Type of contribution
- - 1- HENRIK VANDERLIP------------------------------------------ Person
Payroll27 BALDWIN FARMS SOUTH $ --------- 35,890' Noncash X
(Complete Part II if there isGREENWICH, CT 06831------------------------------------------ a noncash contribution
(a) (b) (c) (d)No. Name , address, and ZIP + 4 Total contributions Type of contribution
- - - - ------------------------------------------ Person
Description of noncash property given(see instructions)
Date received
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JSA
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Schedule B (Form 990, 990-EZ, or 990-PF) (2012)
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schedule B ( Form 990 , 990-EZ , or 990-PF ) (2012) Page 4Name of organization BLAKE ELIN VANDERLI P MEMORIAL FOUNDATION Employer identification number
13-3492208
FTMIM Exclusively religious, charitable , etc., individual contributions to section 501(c)(7), (8), or ( 10) organizationsthat total more than $1,000 for the year . Complete columns (a) through (e) and the following line entry
For organizations completing Part III, enter the total of exclusively religious, charitable, etc ,contributions of $1,000 or less for the year (Enter this information once See instructions) ► $
-------------Use duplicate cooles of Part III if additional space is needed.
(a) No.fromPart I
(b) Purpose of gift (c) Use of gift (d) Description of how gift is held
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(e) Transfer of gift
Transferee's name, address, and ZIP + 4 Relationship of transferor to transferee
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(a) No.fromPart l
(b) Purpose of gift (c) Use of gift (d) Description of how gift is held
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(a) No.fromPart I
(b) Purpose of gift (c) Use of gift (d) Description of how gift is held
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(e) Transfer of gift
Transferee's name, address, and ZIP + 4 Relationship of transferor to transferee
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(a) No.fromPart I
(b) Purpose of gift (c) Use of gift (d) Description of how gift is held
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Schedule B (Form 990, 990-EZ, or 990-PF) (2012)
BLAKE ELIN VANDERLIP MEMORIAL FOUNDATION 13-3492208
ATTACHMENT 1
FORM 990PF, PART I - INTEREST ON TEMPORARY CASH INVESTMENTS
DESCRIPTION
US TRUST SAVINGS ACCOUNT
TOTAL
REVENUEAND NET
EXPENSES INVESTMENT
PER BOOKS INCOME
4. 4.
4. 4.
ATTACHMENT 1
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BLAKE ELIN VANDERLIP MEMORIAL FOUNDATION
FORM 990PF, PART VIII - LIST OF OFFICERS, DIRECTORS, AND TRUSTEES
NAME AND ADDRESS
TITLE AND AVERAGE HOURS PER
WEEK DEVOTED TO POSITION
HENRIK N. VANDERLIP TRUSTEE
C/O VIKING CAPITAL PARTNERS INC. 1.00
27 BALDWIN FARMS SOUTH
GREENWICH, CT 06831
LOUISE VANDERLIP TRUSTEE
C/O VIKING CAPITAL PARTNERS INC. 1.00
27 BALDWIN FARMS SOUTH
GREENWICH, CT 06831
GRAND TOTALS
13-3492208
ATTACHMENT 2
CONTRIBUTIONS EXPENSE ACCT
TO EMPLOYEE AND OTHER
COMPENSATION BENEFIT PLANS ALLOWANCES
0 0
0
0
0 0
0 0 0
ATTACHMENT 2
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BLAKE ELIN VANDERLIP MEMORIAL FOUNDATION
RECIPIENT NAME AND ADDRESS
SEE SCHEDULE #1 ATTACHED
RELATIONSHIP TO SUBSTANTIAL CONTRIBUTOR
AND
FOUNDATION STATUS OF RECIPIENT
N/A
PUBLIC
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13-3492208
PURPOSE OF GRANT OR CONTRIBUTION
GENERAL SUPPORT
TOTAL CONTRIBUTIONS PAID
ATTACHMENT 3
AMOUNT
32,898
BLAKE ELIN VANDERLIP MEMORIAL FOUNDATIONEIN 13-3492208
FOR THE YEAR ENDED 9/30/2013
PART XV SUPPLEMENTARY INFORMATIONGRANTS & CONTRIBUTIONS
RECIPIENT IF RECIPIENT IS AN INDIVIDUAL FOUNDATION
SHOW ANY RELATIONSHIP TO STATUS OF PURPOSE OF GRANT
NAME AND ADDRESS FOUND MANAGER OR CONTR RECIPIENT OR CONTRIBUTION AMOUNT
ROUND HILL ASSOCIATION N/A PUBLIC GENERAL SUPPORT 25.00
ST BARNABAS EPISCOPAL CHURCH N/A PUBLIC GENERAL SUPPORT 1,895.00
GREENWICH PARTY N/A PUBLIC GENERAL SUPPORT 518.00
GREENWICH RIDING & TRAILS ASSOC N/A PUBLIC GENERAL SUPPORT 1,50000
THE VANDERTILL FUND N/A PUBLIC GENERAL SUPPORT 200.00
RED RIBBON FOUNDATION N/A PUBLIC GENERAL SUPPORT 500.00
BRUCE MUSEUM N/A PUBLIC GENERAL SUPPORT 1,00000
ROUND HILL VOLUNTEER FIRE DEPARTMENT N/A PUBLIC GENERAL SUPPORT 100.00
GCDS N/A PUBLIC GENERAL SUPPORT 100 00
AUDUBON GREENWICH N/A PUBLIC GENERAL SUPPORT 50.00
WORLD WIDELIFE FUND N/A PUBLIC GENERAL SUPPORT 16.00
GLOBAL CAMPS AFRICA N/A PUBLIC GENERAL SUPPORT 1,000.00
NEW YORK DOWNTOWN HOSPITAL N/A PUBLIC GENERAL SUPPORT 400.00
BOYS & GIRLS CLUB OF GREENWICH N/A PUBLIC GENERAL SUPPORT 500.00
KENT SCHOOL N/A PUBLIC GENERAL SUPPORT 11,000.00
CHILD GUIDANCE CENTER OF SOUTHERN CT N/A PUBLIC GENERAL SUPPORT 100.00
LE ROSEY FOUNDATION N/A PUBLIC GENERAL SUPPORT 500 00
ETC - ENSEMBLE THEATRE COMPANY N/A PUBLIC GENERAL SUPPORT 1,00000
FRIENDS OF AUTISTIC PEOPLE N/A PUBLIC GENERAL SUPPORT 100.00
FAMILY CENTER'S INC. N/A PUBLIC GENERAL SUPPORT 4,200.00
DOCTORS WITHOUT BORDERS N/A PUBLIC GENERAL SUPPORT 35.00
NAOMA DONNELIEY HAGGIN BOYS & GIRLS CLUB N/A PUBLIC GENERAL SUPPORT 2,500.00
CENTER FOR HOPE N/A PUBLIC GENERAL SUPPORT 125 00
AUTISM SPEAKS N/A PUBLIC GENERAL SUPPORT 5,304.00
CAMPHILL VILLAGE N/A PUBLIC GENERAL SUPPORT 100.00
PRINCETON PROSPECT FOUNDATION N/A PUBLIC GENERAL SUPPORT 50.00
DELRAY BEACH CENTER FOR THE ARTS N/A PUBLIC GENERAL SUPPORT 30.00
GREENWICH COMMUNITY PROJECTS FUND INC N/A PUBLIC GENERAL SUPPORT 50.00
TOTAL 32,898 00
SCHEDULE #1
BLAKE ELIN VANDERLIP MEMORIAL FOUNDATION 13-3492208
FORM 990-PF - PART IVCAPITAL GAINS AND LOSSES FOR TAX ON INVESTMENT INCOME
PKind of Property Description Date Date sold
acquiredGross sale Depreciation Cost or FMV Add basis Excess of Gainprice less allowed / other as of as of FMV over or
ex enses of salea
II wa I RRI-9 12/31/69 12/31169 ad i basis ( loss )
500 SHS JOHNSON & JOHNSON D 03/29/1993 10/18/2012
PROPERTY TYPE: SECURITIES
34,134. 5,129. 29,005.
TOTAL GAIN(L SS) ....... ........................................ 29,005.
JSA2E1730 1 000
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Form 8868 Application for Extension of Time To File an(Rev January2013) Exempt Organization ReturnDepartment of the TreasuryInternal Revenue Service ► File a separate application for each return.
OMB No 1545-1709
• If you are filing for an Automatic 3-Month Extension , complete only Part I and check this box , , , ►• If you are filing for an Additional ( Not Automatic ) 3-Month Extension , complete only Part II (on page 2 of this form)
Do not complete Part II unless you have already been granted an automatic 3-month extension on a previously filed Form 8868
Electronic filing (e-file). You can electronically file Form 8868 if you need a 3-month automatic extension of time to file (6 months fora corporation required to file Form 990-T), or an additional (not automatic) 3-month extension of time. You can electronically file Form8868 to request an extension of time to file any of the forms listed in Part I or Part II with the exception of Form 8870, InformationReturn for Transfers Associated With Certain Personal Benefit Contracts, which must be sent to the IRS in paper format (seeinstructions) For more details on the electronic filing of this form, visit www irs gov/e file and click on a-file for Charities & Nonprofits
Automatic 3-Month Extension of Time. Only submit original (no copies needed).A corporation required to file Form 990-T and requesting an automatic 6-month extension - check this box and complete
Part Ionly ................................................................. ► qAll other corporations (including 1120-C filers), partnerships, REM/Cs, and trusts must use Form 7004 to request an extension of time
to file income tax returns. Enter filer 's identi fy in g number , see instructions
Name of exempt organization or other filer, see instructions Employer identification number (EIN) orType orprint
BLAKE ELIN VANDERLIP MEMORIAL FOUNDATION 13-3492208File by the Number, street , and room or suite no If a P 0 box, see instructions Social security number (SSN)due date forfiling your C/O HENRIK VANDERLIP, 27 BALDWIN FARMS SOUTHreturn, See City, town or post office, state , and ZIP code For a foreign address, see instructionsinstructions
GREENWICH, CT 06831
Enter the Return code for the return that this application is for (file a separate application for each return ) . . . . . . . . . . . 0 1 4
Application Return Application Return
Is For Code Is For Code
Form 990 or Form 990-EZ 01 Form 990-T ( corp oration ) 07
Form 990-BL 02 Form 1041-A 08
Form 4720- ( individual ) 03 Form 4720 THIS FORM HAS BEEN 09Form 990-PF 04 Form 5227 10
FILED BY OUR OFFICEForm 990-T ( sec 401 a or 408 ( a ) trust ) 05 Form 6069 11
Form 990-T ( trust other than above ) 06 Form 8870 ON YOUR BEHALF 12
• The books are In the care of ► HENRIK VANDERLIP THIS IS YOUR COPY
Telephone No ► FAX No ►• If the organization does not have an office or place of business in the United States, check this box , , , , ,, , , , , , , , , , ► q
• If this is for a Group Return , enter the organization ' s four digit Group Exemption Number (GEN) If this is
for the whole group , check this box , , , , , , ► q If it is for part of the group , check this box , , , , , , , ► and attach
a list with the names and EINs of all members the extension is for
1 I request an automatic 3-month ( 6 months for a corporation required to file Form 990-T) extension of time
until 05/15 , 20 14 , to file the exempt organization return for the organization named above. The extension is
for the organization ' s return for
I,.
calendar year 20 or
10. X tax year beginning 10/01 , 20 12 , and ending 09/30 , 20 13
2 If the tax year entered in line 1 is for less than 12 months, check reason q Initial return q Final return
q Change in accounting period
3a If this application is for Form 990-BL, 990- PF, 990-T, 4720, or 6069 , enter the tentative tax, less any
nonrefundable credits See instructions 3a $ 1, 935.
b If this application is for Form 990-PF, 990 -T, 4720, or 6069 , enter any refundable credits and
estimated tax payments made Include any prior year overpayment allowed as a credit 3b $ 1,935.
c Balance due. Subtract line 3b from line 3a. Include your payment with this form , if required, by using EFTPS
(Electronic Federal Tax Payment System ) See instructions 3c $ 0.
Caution . If you are going to make an electronic fund withdrawal with this Form 8868, see Form 8453-EO and Form 8879-EO for payment instructions
For Privacy Act and Paperwork Reduction Act Notice , see Instructions . Form 8868 (Rev 1-2013)
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Form 8868 (Rev 1-2013) Page 2
• If you are filing for an Additional ( Not Automatic ) 3-Month Extension , complete only Part 11 and check this box , , , , , , , , ► X
Note . Only complete Part II if you have already been granted an automatic 3-month extension on a previously filed Form 8868.
• If ou are filin g for an Automatic 3-Month Extension , com p lete onl y Part I ( on pag e 1 )
Additional (Not Automatic ) 3-Month Extension of Time . Only file the original (no copies needed).
Enter filer's identifyin g number , see instructions
Name of exempt organization or other filer, see instructions Employer identification number (EIN) or
Type orprint BLAKE ELIN VANDERLIP MEMORIAL FOUNDATION 1 13-3492208
Number, street , and room or suite no If a P O box, see instructions Social security number (SSN)File by theduedatefor C/O HENRIK VANDERLIPfiling your City , town or post office , state, and ZIP code For a foreign address , see instructionsreturn Seeinstructions GREENWICH, CT 06831
Enter the Return curie for the return that this annIicatinn is for (file a senarate annhcatinn for each return'i . I 01 4
Application
Is For
Return
Code
Application
Is For
Return
Code
Form 990 or Form 990-EZ 01
Form 990-BL 02 Form 1041-A 08
Form 4720 ( individual ) 03 Form 4720 09
Form 990-PF 04 Form 5227 10
Form 990-T ( sec 401 ( a ) or 408 (a ) trust ) 05 Form 6069 11
Form 990-T ( trust other than above ) 06 Form 8870 12
STOP ! Do not complete Part II if you were not already granted an automatic 3-month extension on a previously filed Form 8868.
• The books are in the care of ► HENRIK VANDERLIP
Telephone No ► 203 861-7300 FAX No ►• If the organization does not have an office or place of business in the United States, check this box , , , , , , , , , , , , , , , ► q
• If this is for a Group Return , enter the organization ' s four digit Group Exemption Number (GEN) . If this is
for the whole group , check this box , , , , , , ► q If it is for part of the group , check this box , , , , , , , ► Li and attach a
list with the names and EINs of all members the extension is for
4 I request an additional 3-month extension of time until 08 /15 , 20 14
5 For calendar year , or other tax year beginning 10 /01 , 20 12 , and ending 09/30 , 20 13
6 If the tax year entered in line 5 is for less than 12 months , check reason ' Initial return Final return
q Change in accounting period
7 State in detail why you need the extension AWAITING INFORMATION FROM THIRD PARTY SOURCES
NECESSARY TO FILE A COMPLETE AND ACCURATE RETURN
8a If this application is for Form 990-BL, 990-PF, 990-T, 4720, or 6069, enter the tentative tax, less any
nonrefundable credits See instructions 8a $ 1, 935.
b If this application is for Form 990-PF, 990-T, 4720, or 6069, enter any refundable credits and
estimated tax payments made. Include any prior year overpayment allowed as a credit and any
amount paid previously with Form 8868 8b $ 1,935.
c Balance Due. Subtract line 8b from line 8a Include your payment with this form, if required, by using EFTPS
(Electronic Federal Tax Payment System) See instructions 8c $
Signature and Verification must be completed for Part II only.Under penalties of perjury, I declare that I have examined this form, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct, and complete, and that I am authorized to prepare this form
